Category: Head Injury

Head Injury

Background

  • Defined as any traumatic injury to the head other than superficial facial injuries.
  • The commonest cause of death and disability in people age 1-40 in the UK.
  • Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.

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Minimal and Moderate Paediatric Sedation

The depth and type of sedation required in children depends on the procedure to be carried out.

Sedation is described as:

Minimal – Drug induced calm, the patient is awake and responds to verbal commands but may have impairment of cognition and coordination.

Moderate – Drug induced depression of consciousness but patients respond purposefully to verbal commands or tactile stimulation.

Deep – Drug induced depression of consciousness during which patients are asleep and cannot be easily roused, respond to painful stimuli.

Dissociative – Ketamine Sedation produces a trance like state.

 

Painful procedures preformed for children in the ED are usually done with Ketamine Sedation for which there is a separate pathway – Ketamine Sedation

 

Minimal and Moderate Sedation

Painless procedures such a diagnostic imaging do not require Ketamine or Opioids therefore drugs such as oral Chloral Hydrate or Buccal Midazolam should be considered, neither of these require cannulation.

Who can preform minimal/moderate sedation?

  • Senior medical staff (ST3+) with paediatric life support training
  • Must have done at least 6 months of anaesthetics/ICU
  • Familiar with giving medication of choice
  • Must have at least 2 staff members – someone to perform sedation, someone to monitor the patient
  • Department must be safe – Senior ED Clinician in charge (Consultant or Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.

Contraindications

Any of the following comorbidities / contraindications require discussion with an anaesthetist / senior paediatrician:

  • Abnormal airway – including large tonsils or craniofacial anomalies e.g. receding jaw, stiff neck, restricted mouth opening, very large head
  • Raised intra cranial pressure or depressed conscious level
  • History of obstructive sleep apnoea
  • Major organ dysfunction including congenital cardiac anomalies
  • Moderate to severe gastro oesophageal reflux disease
  • Neuromuscular disorders
  • Bowel obstruction
  • Intercurrent respiratory tract infection
  • Known allergy to sedative drug / previous adverse reaction
  • Multiple trauma
  • Refusal by parent / guardian / child
  • Corrected age < 1 year because of severe prematurity
  • ASA 3 or more

Fasting

  • For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
  • Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
    • 2 hours for clear fluids
    • 4 hours for breast milk
    • 6 hours for solids and formula milk

Medications

Chloral Hydrate

Oral – give 45-60 minutes before procedure, it has an unpleasant taste but can be mixed with blackcurrant squash

Dose: –

Minimal Sedation: 30-50 mg/kg Maximum 1g

Moderate Sedation: 100mg/kg Maximum 2g

Side Effects

Gastric irritation including nausea and vomiting reported.

Beware cardiac arrhythmias and respiratory depression with loss of airway reflexes at high doses.

There is NO reversal agent available

Buccal Midazolam

Buccal: Give 15 minutes pre-procedure and give half the dose into each side of the mouth

Dose: –

1-9 years:  0.2mg – 0.3mg/kg; Maximum 5mg

10-18 years:  6mg – 7mg; Maximum 8mg if 70kg or over

Side Effects

Short acting benzodiazepine causing sedation, hypnosis, anxiolysis, anterograde amnesia

Beware respiratory depression / hypotension / loss of airway reflexes at high doses.

Can lead to a distressing paradoxical excitement in children

Reversal agent: Flumazenil

Flumazenil dose: 10 microgram/kg [Max 200 microgram], repeat at 1 minute intervals up to 5 times.

 

Post sedation care

  • Observe for 1-2 hours until:
    • Conscious and responding appropriately
    • Able to walk unassisted (older children)
    • Vital signs are within normal limits
    • Respiratory status not compromised
    • Pain and discomfort addressed
  • No food or drink for 2 hours after discharge (risk of nausea and vomiting)
  • Supervise child closely for 24 hours no driving for older children
  • Give advice leaflet to parents/carer
  • Ensure that sedation documented on EPR and drugs are signed for in CD book

Full trust policy is available on intranet here